Report Date


Case Against

A GP Surgery in the area of Cwm Taf Morgannwg University Health Board


Clinical treatment outside hospital

Case Reference Number



Upheld in whole or in part

In 2010 Mrs X was diagnosed with Alzheimer’s dementia and Mr X became her main carer. There were ongoing consultations with the local Psychiatry Team, Old Age Psychiatry Team, Community Psychiatric Nurse and the Drugs for Dementia Team. On 14 January 2020 Mrs X was prescribed 50 mgs of sertraline (an antidepressant), and by 15 May the dosage was increased to 150 mgs. On 18 August Mrs X went into a Residential Home (“the Home”) for respite care. On 26 August the Home called the Practice and told the GP that Mr X had not been administering sertraline to Mrs X, and the GP noted that sertraline had been increased from 100mgs to 150 mgs and it should continue. Mrs X’s mobility deteriorated and she had to be hoisted, her physical condition deteriorated and she was moved to a Residential Home for nursing care.

Mr X complained that as the main carer, the Practice inappropriately prescribed Mrs X medication without consulting him to query the discrepancy in medications prescribed to ensure the information was correct.

The Ombudsman found that on 26 August as the GP noted that Mr X was not administering sertraline to Mrs X, Mr X should have been contacted to clarify why and when the administration of sertraline stopped, whether he followed psychiatric instruction or whether it was his decision. Such contact might have highlighted that the administration of 150 mgs was inappropriate. On this basis only, the Ombudsman upheld the complaint.

The Practice agreed to implement the Ombudsman’s recommendation to apologise to Mr X for this failing.